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MEDICA 

OF 

ADDRESS 

Chairman Comm 

BEFORE THE 

WOMEN'S 

VILLE, 

State Boar 

E 


L INSPECTIO 
SCHOOLS 


N 

I 

OF 


OF DR. HIRAM BIRD 

ittee on Public Health and Sanitation 


STATE CONFERENCE 
CLUBS, AT JACKSON- 
FLA., NOV. 14, 1911 


d of Health of Florida 

1912 

. O. PA INTER PRINTING CO. 

OE LAN D, FLA. 



PUBLICATION 96 JUNE, 1912 



MEDICAL INSPECTION 
OF SCHOOLS 



ADDRESS OF DR. HIRAM BIRD J 3 8H 

Chairman Committee on Public Health and Sanitation 



BEFORE THE STATE CONFERENCE OF 
WOMEN'S CLUBS, AT JACKSON- 
VILLE, FLA., NOV. 14, 1911 



State Board of Health of Florida 






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MEDICAL INSPECTION OF SCHOOLS. 



By Dr. Hiram Byrd. 



Ladies and Gentlemen: 

At a meeting of this kind, held two hundred years ago, we 
would have discussed mischievous sprites and elves and witches, 
as the cause of disease; and incantations, sorcery, and ceremo- 
nies as the remedies. We would have heard that Sir Kenelm 
Dig-by' s sympathetic applied to the sword, would heal the wounded 
soldier; we would have heard that four or six big fat snakes put 
in a gallon of canary wine alive and left four to six months would 
make a medicine that would provoke to love and cure the small- 
pox ; and a little later we would have heard that a certain German- 
American Doctor by the name of Cagliostro had discovered the 
truly elixir of life, that would change all metals into gold and 
keep people forever, young. 

In the days of the celebrated Divine, Cotton Mather, if we 
had had a meeting of this kind, every homely and eccentric old 
woman in the community would have, been discussed, and dissected, 
and condemned and tortured into confession of witchcraft, and 
then burned at the stake because she had confessed. 

Just one hundred and two years have now elapsed since the 
birth of the man who was destined to usher in a new era in learn- 
ing — an era* which was to abolish dogmatism and institute experi- 
ment; an era that was to ignore opinion however venerable with 
age it might be, and accept nothing but proof ; an era that was 
to subject every item in the domain of human knowledge to the 
most exacting test that science could devise, and reject every 
particle that could not stand the test. 

But while Darwin ushered in this new era, by rejecting the 
dogmas with which the world was teeming, and by inductive rea- 
soning set up new standards of truth, and opened the way for the 
scientific study of biology, and himself coined the expression, 
"The strugle for existence," which is the nucleus around which 
all biological phenomena group themselves, he did not understand 
its full significance. He saw some three thousand species of 
animals, and some two hundred and fifty thousand species of plants, 
all turned loose in the world together, all struggling with adverse 
conditions to maintain their own existence ; plants struggling with 



4 MEDICAL INSPECTION OF SCHOOLS 

one another for soil, light, warmth, moisture; animals struggling 
with one another for food, place, supremacy; plants struggling 
with animals to keep from being eaten, animals struggling with 
plants to make them available for food; every one for self, hav- 
ing no care except to get all possible and turn it to its own 
account, and no fear except the fear of being used for food z>r 
otherwise consumed by some stronger, some more ingenious appe- 
tite. 

And in that fierce struggle, how many animals, how many 
plants, must daily, hourly perish. How many blades of grass to 
feed a single caterpillar! How many caterpillars to feed a spar- 
row ! How many beetles for a toad ! How many toads for an ad- 
der! How many sparrows, toads, adders, to feed a single hawk! 

Darwin saw in the struggle for existence, that slow but con- 
stant change that makes for new varieties, as the farmer by care- 
ful propagation can produce different varieties of corn, as the 
Cuban, the shoe peg, the Blitch; as the stock man by systematic 
breeding can produce from common cattle, the Hereford, the Short- 
horn, the Jersey. And as the propagation continued through the 
ages he saw the difference become greater and, greater, the va- 
rieties diverge into species, as the dog, the wolf, the coyote, 
that came from a common ancestor ; and he saw species diverge in- 
to genera, and on up through the scale — the struggle for exis- 
tence weeding out the weaker, the survival of the fittest propagat- 
ing the kind. 

But while Darwin saw all this in the world of larger things, 
he never followed it into the domain of disease. That work was 
reserved for another. Where Darwin laid it down, his illustrious 
contemporary, Pasteur took it up, and demonstrated for the first 
time in the history of the world that what we know as disease, is 
nothing more or less than the phenomena of the struggle for ex- 
istence ; that the struggle is not confined to the higher animals 
or higher plants, but penetrates every part of the organic world, 
from the lion making food of the buffalo to the malarial parasite 
making food of the human blood ; from the mistletoe penetrating 
the oak with its roots to the tubercle bacillus penetrating the 
human lungs, Darwin's observations had been confined to the world 
visible ; Pasteur's keen mind took it on into the world invisible. 
And here he saw the struggle just as fierce as in the world of 
larger things. Saw that sickness is an accident — the result of 



MEDICAL INSPECTION OF SCHOOLS 5 

some smaller animal or plant trying to make a living, trying to 
get food and shelter — may be some coarse parasite, as the tape- 
worm in the intestine of the cow, or some smaller one, as the 
hookworm sucking the blood of the child, or it may be some still 
smaller worm as the trachina that embeds itself in the muscle of 
the pig and causes measly pork, or indeed the attacking parasite 
may even be too small to be seen without a microscope, as the 
malarial parasite in the human blood, or the tubercle bacillus 
in the lungs. Size makes no difference — the struggle is none the 
less fierce because one of the combatants happens to be microscopic 
in size. The objects of the combat are the same — the result the 
same as in the higher world. 

I say it was Pasteur that extended our knowledge of biology 
into the lower world. He could not see it in all its fullness and 
richness at that early time, for he was the first to look. Much 
long and patient labor was to be performed before the basic prin- 
ciples were to be laid bare. Pasteur did much of the work him- 
self, and showed how it could be done, and as if his call in be- 
half of humanity had been magic, a thousand laborers instantly 
responded and soon the dyke of ignorance and superstition that 
held the people in thrall since the beginning of the world, was 
broken and a flood of knowledge like a mighty torrent came rush- 
ing through, and sweeping on and on. Thought once awakened 
does not slumber again. It grows in man after man, generation 
after generation. And ever as it grows it becoms more and more 
democratic. At first only seen by the seers, truth at length becomes 
a household word, and little children see more danger in the house 
fly today, 

"Than ever the sages 
Of the earlier ages saw." 

So prompt was the response to his call that even during his 
life time, Pasteur saw that knowledge working like the ferment 
that he had discovered throughout the length and breadth of the 
land. First, physicians taking advantage of the fact that disease 
is a living process in the interest of their patients; then sanitarians 
taking advantage of it to prevent disease; and then everybody 
from one end of the earth to the other, waking from their 
lethargy and joining in the mad rush for less disease, better 
health, and more happiness. Witness the hundred and one or- 



6 MEDICAL INSPECTION OF SCHOOLS 

ganizations for the study and prevention of tuberculosis alone, the 
endowments for tuberculosis hospitals, the dispensaries, the prizes, 
the legislation, the international meetings, that this disease alone 
has called into existence! And then reflect that tuberculosis has 
not received more than its proportionate share of the study that 
has been done on the other major maladies that afflict mankind. 
That diphtheria, malaria, typhoid, cholera, plague, smallpox, 
pellagra, hookworm, infantile paralysis, have all been accorded 
attention according to their importance. 

Early in the study of these several diseases, it was discerned 
that none of them could be successfully coped with except by in- 
telligence — an intelligence of the highest order. That malaria was 
both a scourge and an enigma as long as the life struggle between 
the malarial parasite and its host was unknown — as long as it 
was unknown how the parasite managed to pass from host to host. 
The first successful management of malaria was after it was 
discovered that the mosquito serves as intermediate host for the 
parasite. 

To combat disease successfully means that not only the phy- 
sicians and health officers must have adequate knowledge of its 
cause and method of transmission, but that the entire population 
must likewise know the inmost secrets of the same that they might 
give their intelligent co-operation. Or to state it another way, 
we are engaged with our microscopic foes in a hand to hand strug- 
gle for existence — and whether we will better our condition, or 
be the easy prey that we have always been, depends upon whether 
we will enlist intelligence on our side. To state it still another 
way, public health is a matter of public education. And oh, that 
is such a tedious — such an eternal undertaking! To educate the 
public. To bring the rank and file to an appreciation of the things 
that we think are worth while! That is work, that is labor. For 
. a hundred years we have known how to prevent smallpox, and 
yet nearly a hundred thousand people in the United States had 
the disease last year! For fifteen years we have known that 
malaria was transmitted solely by mosquitoes and yet some of our 
school physiologies even of to-day state that the disease may 
come from miasmatic effluvia — whatever that is. For fifteen 
years we have been harping on the life of the mosquito as a factor 
in the spread of malaria, and more recently of yellow fever, and 
how the insect breeds only in water, and yet we hear spasmodic 



MEDICAL INSPECTION OF SCHOOLS 7 

spurts and sputtering about the negligence of the health authorities 
because of weeds that are alleged to be breeding mosquitoes! Oh 
what a task when we undertake to educate the public. 

So hopeless is it that it is now being recognized more and 
more that the point of attack must be the child and not the parent. 
That the place to educate the child is the public school. That it 
will take an army of educators, and these we have in the teachers 
of the country. That education along public health lines is only 
a part of the work of educating the child for its future usefulness 
and happiness. 

When Pasteur made his famous discovery that the diseases of 
silkworm, known as pebrine and flacherie, were due to parasites, 
and were preventable, and then in rapid succession discovered the 
cause and method of prevention of chicken cholera, and anthrax, 
and swine erysipelas — discovered that they were all parasitic disea- 
ses, the world stood aghast and wondered. These new doctrines 
were so different from the things they had heard, that they were 
dazzled. Suddenly one, and then another caught the spirit — 
saw the light, and soon a thousand workers sprang through the 
gate he had opened, some to learn more of the new science, and 
some to pass the learning around that more and more might profit 
by the treasures that he had garnered. And round and round it 
was passed till the children were reached, and even in the life of 
that venerable sage, medical inspection of schools was established 
on the very spot where two centuries before the witches were burned. 
And. from that small beginning in Boston seventeen years ago, the 
movement has spread to over a thousand cities in America, has 
spread to Canada, England, Scotland, Germany, even far Aus- 
tralia, and in some form or other has found anchorage in eyery 
enlightened nation on earth. 

Wherever medical inspection of schools has been instituted, 
regardless of size of city, or amount of expenditure, regardless 
of the agencies employed in its execution, one thing has always 
figured as one of the first objects to be attained ; namely the preven- 
tion of communicable disease. Other things vary in different- 
locations but that is universal. 

It must not be assumed for an instant though, that the methods 
employed for this are the same. They vary greatly. Just so the 
diseases to be prevented vary. Each country has its own public 
health problems. The far east has among its major" problems, 



8 MEDICAL INSPECTION OF SCHOOLS 

plague and cholera. The West Indies, and tropical America has 
as its major problem, yellow fever. Africa has among the more 
important diseases sleeping sickness. The larger cities of the 
world are more infested with vermin and skin diseases ; the country, 
with sewage-borne diseases. 

And even the public problems of the same locality vary from 
year to year, from decade to decade. One year we will have an 
abundance of one communicable disease and another year another. 
One year we may have more diphtheria, another year more scar- 
latina, another more measles, or whooping cough. 

Prior to 1898 plague was unknown in the United States. Then 
it got introduced into San Francisco and has been like a mine 
under the place ever since, while the eastern states have still enjoyed 
freedom from it. 

If we of Florida had been discussing our major diseases 
twenty years ago, yellow fever would have had the foremost place, 
while to-day it would hardly get a passing mention, but we would 
hear of a new and fatal disease of rapidly increasing prevalence, 
known as pellagra. Ten years ago we would not have heard men- 
tioned the hookworm, while to-day it stands in the scale of im- 
portance second to none. 

So it is patent that all effort to prevent communicable disease 
must crystallize in accordance with the needs of the community. 

The second object to be attained is the correction of physical 
defects. In the Borough of Manhattan, New York, 275,000 school 
children were examined and the astonishing fact revealed that 
something over 71 per cent, needed medical treatment in some form 
or. other. 49 per cent, had defective teeth, We are not surprised 
then to find that 45 per cent, had diseased glands, 27 per cent, had 
enlarged tonsils, 16 per cent, had nasal growths, 15 per cent, had 
obstructed breathing, one out of five children had defective vision. 

It is not likely that we have the same physical defects in this 
state to the same degree. In Ocala last year it was found that 
one out of eleven had defective vision, instead of one out of five. 
But, on the other hand, we have other defects just as serious to 
take their place. Indeed, we have a disease, common to tropical 
countries, quite as prevalent, and vastly more important, than any 
of those named. A disease that I hesitate much to discuss in this 
connection, because it has been in the lime light so long, but its 



MEDICAL INSPECTION OF SCHOOLS 9 

pre-eminent position in the scale of serious maladies will not 
permit us to pass it lightly by. 

Let us pause here long enough to see if we can get the full im- 
port of this one disease. 

White people suffer from it more than negroes. 

Children suffer from it more than adults. 

The rural population suffers from it more than the urban. 

Our inquiry will be then to determine the cost in dollars and 
cents that hookworm disease entails upon our rural white children. 

55 per cent, of our people are white. 70 per cent, of Our 
people live in the country. Therefore 28 per cent, of our white 
school children live in the country. 

A canvass was made by the State Board of Health covering 
six thousand rural school children and it was found that 52 per 
cent, of them were hookworm sufferers. 

From which it is seen that 15 per cent, of the total school 
children of the state are suffering from hookworms. 

The extent to which the sufferer's vitality is lowered varies. 
But it can be measured with a fair degree of accuracy by the color 
of the blood. That is to say, rich, healthy deep red blood is in- 
dexed at 100. The hookworm sufferer's blood becomes pale and 
watery in proportion to his infection. And as the infection gets 
worse and worse the color index of the blood runs down and down, 
90, 80, 60, and even to 20 per cent, of the normal. Perhaps an 
average color would be 70 per cent. But, to be especially conser- 
vative, we will assume that it is not SO' low as that. We will 
assume that it is 80 per cent. That means that the sufferer is off 
20 per cent, in strength, 20 per cent, in intellectual energy, 20 per 
cent, in power of learning. 

Now if 15 per cent, of our school children are off 20 per cent, 
in power of development, that lowers the whole power of devel- 
opment of the school children of the state by three per cent. 

We expend upon our public education now about two million 
dollars a year. Three per cent, of two million dollars is sixty 
thousand dollars. 

Are these figures facts? Verify them for yourselves. Sixty 
thousand dollars of our all too scant educational fund wasted an- 
nually — literally devoted to the maintenance of hookworms. Sixty 
thousand dollars for hookworms, and we haven't taken into account 
any of the negro population. Sixty thousand dollars' loss, and 



IO MEDICAL INSPECTION OF SCHOOLS 

we haven't taken into account any children under or over school 
age. Sixty thousand dollars' loss annually, and we have left out 
of consideration all the people of the cities and towns with a pop- 
ulation of over one thousand, and aggregating 30 per cent, of 
our entire population. 

Remember, now, that sixty thousand dollars represents only 
a part of the loss from a single disease; and remember that every 
•disease represents a distinct money loss, some greater, some less, 
but in all cases a loss ; and remember that all the loss represented, 
by disease would be saved by curing and by preventing the dis- 
eases, and then stop and ask yourself — Don't ask yourself if you 
can afford to have medical inspection of schools, but ask yourself 
if you can afford not to have it. 

The third object to be attained is the education of the public. 
And this is the most important of the three, for, after all, con- 
servation of the public health is a matter of education pure and 
simple. What the children are taught to-day represents the great- 
er part of what the men and women of to-morrow will know. And 
they can never be taught by simply telling them how. They must 
be shown. It is an aphorism in educational circles that we learn 
to do by doing. We learn to prevent sickness by putting into 
operation the measures that will prevent it. We learn to correct 
physical defects by correcting them. Wq have had agricultural 
schools for years, many ) r ears, but it was only recently that agri- 
culture was actually introduced into them. The corn clubs of 
to-day will teach more agriculture in a year than the agricultural 
school would ever teach without it. It is learning to do by doing. 
So it is with, the public health. If we would conserve it, we must 
teach our people how, and we must teach them how to do it by 
doing it. 

With this method we don't have to wait till the next generation 
for results. The children learn now and so do the parents. There 
is no more effective way of disseminating general sanitary informa- 
tion than through the schools. This, again, the corn clubs have 
verified. Boys have joined the clubs and have taught the fathers 
things that they couldn't have been taught in any other way. 

The forces employed in medical inspection of schools will of 
necessity vary according to the density of the population, the avail- 
able funds, and the spirit of the populace. In" the larger cities. 
where the matter is taken up, as London, New York, Boston, 



MEDICAL INSPECTION OF SCHOOLS II 

Glasgow, Frankfort-on-Main, and so on, an adequate corps of 
physicians and nurses is employed, which, together with provision 
for dental clinics, constitute a complete system of medical super- 
vision. But smaller places have to be content with less. The 
nurse may be dispensed with, and in the still smaller, where avail- 
able funds become an object, the services of the physician and den- 
tist may be placed upon a gratuitous basis. In over 75 cities in 
the United States having medical inspection of school children, 
the doctors receive no compensation. 

But the most important factor in medical inspection of schools 
is the teacher. And this is true even where doctors and nurses 
are available. Not that the teacher does or can displace either 
the doctor or nurse — that cannot be done, but that the teacher is 
an indispensable adjunct, and can do much, even where there is 
neither doctor nor nurse. In London, where the scheme has been 
developed largely after the ideas of Dr. Kerr, who is probably 
the foremost thinker of the time along these lines, the greater part 
of the responsibility for the control of communicable diseases rests 
upon the teacher. To outline this responsibility a little better, 
the teachers keep on the alert for cases of communicable disease, 
and as soon as they suspect a case it is reported to the school 
physician . or nurse, as the case may be. In other words, the 
teacher doesn't undertake to make a diagnosis of measles or scar- 
let fever or diphtheria, but does undertake to determine whether 
a child is sick or well, and if sick it is reported to the doctor. So 
important a factor is the teacher in medical inspection of schools 
that even the work of testing the eyes is done by the teacher in 
Massachusetts, and the results are reported as being satisfactory. 
Here, again, the teacher does not undertake to make a diagnosis 
of eye troubles. She only undertakes to determine whether the 
eyes are normal or defective, and if anything is found to be 
wrong, the student is referred to an eye specialist at once. There 
is no attempt on the part of the teacher to do more than determine 
whether; the eyes of the child need examination by an eye specialist. 

In this state the teachers have, I might say, unconsciously taken 
up medical inspection of school children to the extent of suspect- 
ing hookworm infection here and there and referring them to 
the family physician and the State Board of Health, and tubercu- 
losis in, school is frequently taken cognizance of by the teacher 
and advice sought, and the same thing might be said of sore eyes, 



12 MEDICAL INSPECTION OF SCHOOLS 

and ring worm, and smallpox, so that little by little a system of 
medical inspection is growing up under the impulse of necessity. 
In one of the larger schools last year, not the mentally defective, 
but simply the duller pupils, were all taken from the entire school 
and put into a single room and managed as an ungraded school, 
with very satisfactory results. 

In this connection it is pertinent that I should outline what 
experience has taught is the line of least resistance in bringing 
it to pass. 

First of all, legislation authorizing it. In the case of Boards 
of Health taking it up, they usually have sufficient legislation to 
insinuate it in. 

And fortunately it happens that in this state the educational 
law is wide enough in its wording and meaning that whenever a 
school board wants to devote a part of the school fund to looking 
after the physical needs of the school and school children, it can 
do it. So that the need for additional legislation is at once dis- 
posed of. The existing machinery is all sufficient. 

Next is some one to take the initiative. It may be the Wom- 
ans Club; and there are some forty Womans Clubs in the state 
federation, and no one knows how many that are not. It might be 
the Womans School Improvement Association. There are some- 
thing like 150 such organizations in the state, whose excuse for ex- 
istence is what the name implies. Or it might be the local Board of 
Health, as in Jacksonville; or the local board of education, or, in- 
deed, the principal of a school, as in Madison and many other 
places. It is not practicable for a State Board of Health, or a 
state board of education, to more than make provision for it — 
it cannot be executed upon a state-wide scale. Even in Massa- 
chusetts, where provision is made for it for the entire state, its 
institution and execution depend upon the local authorities. 

And the same is true in Scotland, Australia, everywhere. The 
State Board of Health or the state board of education can make 
provision for it, can make it possible, but the local authorities 
must bring it to pass. 

Summed up, or boiled down, then, any school in the state 
that wants medical inspection can have it — the thing required is 
the necessary effort to bring it about. 

It is easier to bring it about in the larger places than in the 
smaller ones, and, other things equal, medical inspection will first 



MEDICAL INSPECTION OF SCHOOLS 13 

take shape in the larger cities of the state, and from these it will 
gradually work its way down through the towns of smaller and 
smaller magnitude. And once it is started there is reason to be- 
lieve that it will so justify its existence that it will go on down 
and down, till even the smallest aggregate of pupils will eventu- 
ally undergo some form of medical inspection. 

In like manner the medical inspection will be more thorough 
in the larger places, certain features being dropped off as the 
smaller and smaller places are reached, till only the most essential 
phases will be retained in the smallest aggregates. 

And it might with safety be added that as time passes medical 
inspection will come to be more and more simplified, and pari passu 
more and more complete in any given community, and at the same 
time the smaller place will come to be larger, so that the institu- 
tion will be an ever growing one toward perfection and usefulness. 

If I read the signs of the times aright, medical inspection of 
schools is not only coming, bmt is already here, and here to stay. 
It is based upon the eternal principles of progress, and, like the 
Chinese revolution, is gathering momentum as it goes. At first, 
disorderly, perhaps, its energies will not always be expended to 
best advantage; and here and there it will encounter royalists, who 
do not believe in it; but ever and anon it can point with pride to 
the things already accomplished that more than justify its exist- 
ence, as in London, for example, where ringworm was so common 
that a ringworm school was established, but had to be closed after 
three years for lack of pupils; as in Bradford where schools are 
conducted in open air for children of tuberculous tendencies; as 
in Madison, Fla., where the prevalence of hookworm disease has 
been reduced during the last eight years t^ the point where it is 
all but eradicated. 

It is to the eternal credit of the Womans Clubs that they are de- 
voting their energies to such worthy objects. If ever woman suf- 
frage comes to pass, it will be brought about, not by fanatics ex- 
hibiting themselves as suffragettes, but by the eloquent, the silent 
appeal of the good women of the country who demonstrate their 
ability to discern and to do. 



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